10/30 Eddie AMPS 421 +3.5 427 PMPS 428

[Jodey&Eddie&Blue]

Good morning, finally!

Eddie and I have been in Victoria at the VCA clinic since October 23rd. Eddie was on 27u Levemir BiD at the time and had been on it for awhile (see SS). While in Victoria Eddie received three fractions of SRT for his acromegaly and actually came through the entire process with flying colours.

I cannot attribute the same flying colours to my experience of the clinic. It was almost impossible to get any information on his BG or for that matter what dose of insulin they were giving him. The "homecare" instructions I received at the end is equally mysterious. It says he had a hypo event the first time they gave him insulin and appears to say that they didn't give him insulin for a day or so, at all. Somehow, they have him on 10u and apparently that was the case for the last few days (he was in clinic for 5 nights: our arrival, his CT scan and then 3 separate days for SRT, one each day). If this sounds confusing to you, believe me, I am even more confused as I tried so many times to get information and even when I did it was contradictory.

The long and short of it (I just can't adequately describe the stress and the confusions over the past week), is that we are now home. Eddie's SRT will probably result in a decrease in his insulin requirements (recall he was on 27u and is now on 10u [Go figure. How did they come up with that number?] or even cease insulin altogether.

What I am dealing with right now is the question of dose. I have to be mindful of his numbers because too much insulin can be dangerous if the SRT starts to put the boots to the tumour and it no longer secretes GH (which makes him insulin resistant). But I also see that his insulin dose is too low at the moment.

I've started recording again as I had to give Eddie a day or so at 10u just because we did all that travelling. Moreover, because he had SRT, he needs to take a high dose of Prednisolone (10mg/once daily) until November 11th and then reduce (5u/once daily) "until otherwise directed". I understand Pred raises BG so there's that balancing act as well.

So, what am I asking? @Wendy&Neko what do you think? Should I increase 1u/2u? Again, he's on Prednisolone until Nov 11th and onwards. Prior to all this he was on .625 mg Prednisolone once daily...

The good news is that Eddie is doing really well. He tired of course but he's got the 5Ps happening. He even jumped up on the bed and slept in the crook of my arm, something he hasn't done for over a year...

I might add, which has nothing to do with VCA but while in Victoria my friend and I took a daytrip drive to offset the stress of worry about Eddie and on the way to Port Renfrew the wheel of my car was damaged. I was told it may be the CV joint when I brought it to Victoria Nissan; they said no parts until October 31st and I was freaking out because what was I going to do with Eddie and getting back to Kelowna. It turned out to need ball bearing replacement and they actually fixed the car within 3 hours even though they said they were so busy they would not be able to get to it until Friday, which is when we were to return home. I told them about Eddie and somehow it got through to them and they fixed the car.

There is so much to this story but I'll leave it at getting Eddie at home again. I am so relieved to be home with him.

 

[carfurby (GA)]

I don't know about the dose. I'm glad the SRT went well and hope you'll see better numbers soon. Sorry things were so frustrating with getting information about his numbers and dose. Glad they got your car fixed so quickly.

 

[Wendy&Neko]

I am so glad you are home safely and Eddie made it through the ordeal. Hopefully that's his last big vet trip anywhere.

And expectations setting, second SRT does not ensure OTJ. Neko is proof of that. She did get on tiny doses which I was thankful for as it meant less growth hormone output. As hard as it is, be thankful for improvements you do see, don't expect to see remission. It is possible, but don't count on it.

SRT typically takes at least 2 weeks to start working (unless the cat is named Neko ), and for some cats it can take months. In the mean time, you don't want him on too low a dose. And I've seen plenty a cat whose dose actually had to go up after SRT, until the SRT started taking effect. We've had cats on way higher doses have SRT and people managed it just fine. SRT changes are gradual, not a sudden plummet in dose. SRT neuters the tumour cells, so you get dose reduction action as the existing tumour cells gradually die off.

Can you tell me why Eddie needs to have such a high dose of pred post SRT? I've only rarely seen cats here have pred after SRT. Exactly one of the many here that have had SRT, and that was for some inflammation caused by the intubation tube. Neko never did. The CSU vet it was a possibility, but it wasn't needed.

In light of what I've said, given that you want to be conservative, maybe start with 25 units and wait until that depot builds and go from there. Likely you will have to increase after that. Partly because 27 was a decent dose and 25 is less, and partly because pred will mean he needs more;.

You might want to study the spreadsheets of a few kitties that have had SRT. Max is a recent one, his SS here. 10/14/21 was the start of his treatment. He's now on about half the dose he was at SRT start. I can rustle up some more spreadsheets (Neko too) if you want.

 

[Jodey&Eddie&Blue]

I am so glad you are home safely and Eddie made it through the ordeal. Hopefully that's his last big vet trip anywhere.

And expectations setting, second SRT does not ensure OTJ. Neko is proof of that. She did get on tiny doses which I was thankful for as it meant less growth hormone output. As hard as it is, be thankful for improvements you do see, don't expect to see remission. It is possible, but don't count on it.

SRT typically takes at least 2 weeks to start working (unless the cat is named Neko ), and for some cats it can take months. In the mean time, you don't want him on too low a dose. And I've seen plenty a cat whose dose actually had to go up after SRT, until the SRT started taking effect. We've had cats on way higher doses have SRT and people managed it just fine. SRT changes are gradual, not a sudden plummet in dose. SRT neuters the tumour cells, so you get dose reduction action as the existing tumour cells gradually die off.

Can you tell me why Eddie needs to have such a high dose of pred post SRT? I've only rarely seen cats here have pred after SRT. Exactly one of the many here that have had SRT, and that was for some inflammation caused by the intubation tube. Neko never did. The CSU vet it was a possibility, but it wasn't needed.

In light of what I've said, given that you want to be conservative, maybe start with 25 units and wait until that depot builds and go from there. Likely you will have to increase after that. Partly because 27 was a decent dose and 25 is less, and partly because pred will mean he needs more;.

You might want to study the spreadsheets of a few kitties that have had SRT. Max is a recent one, his SS here. 10/14/21 was the start of his treatment. He's now on about half the dose he was at SRT start. I can rustle up some more spreadsheets (Neko too) if you want.

I'm not really expecting remission but who knows what Eddie has in mind. Blue went into remission after about a week following SRT. I don't see them being the same but, well, again, who knows.

The high dose of Pred is aimed at reducing inflammation of the brain tissues post-radiation. That's what I'm told by the RadOnc vet and I have little experience dealing with that end of things.

But for the dose: he's on 10u now. Are you saying to go up to 25 now, that is, without gradual increase?

I'll look at the SS. Thank you!!

 

[Wendy&Neko]

Yes go straight up in dose. Consider what he had as a "petsitter" or holiday dose. We go right back up to the last good dose.

The idea behind SRT, is that it does not produce inflammation like regular radiation therapy, because it's many smaller radiation doses, and the beam is on a gantry shooting them from several different directions, so you don't get beams on the same path, except at the site of the pituitary where they intersect. Other than a higher insulin dose needed, the extra pred should not hurt, as long as his heart can manage it.

 

[Jodey&Eddie&Blue]

Yes go straight up in dose. Consider what he had as a "petsitter" or holiday dose. We go right back up to the last good dose.

The idea behind SRT, is that it does not produce inflammation like regular radiation therapy, because it's many smaller radiation doses, and the beam is on a gantry shooting them from several different directions, so you don't get beams on the same path, except at the site of the pituitary where they intersect. Other than a higher insulin dose needed, the extra pred should not hurt, as long as his heart can manage it.

Oh, dear Wendy, if he had not had all the variables--including the unknowns over the week, I'd go to that dose as if it was a "petsitter" dose. I have far more confidence in my petsitters than the VCA. Recall they told me he was hypo (52). Was he? If so, why? Was it too early to give insulin? Did he have insulin over the next few days? They indicate he did not but I'm not confident in that either. No one has told me why he is at 10u. Who decided? Why 10? Who knows? No one.

So, I get it that I asked but I'm anxious enough after all that to be conservative (maybe too much but hyper is better than hypo) or err on the side of caution and increase by 2u to start. I hope this makes sense.

 

[Wendy&Neko]

You hold the syringe, you can increase what you feel comfortable doing. I do recall you said he was "hypo", but was it because they either didn't shoot the right amount or shot earlier than they should have? Or was he not eating enough? Or did he genuinely earn a reduction down from 27 units down the next dose, which at his size dose would be 24-25 units. That was part of the thinking behind my suggestion to reduce his dose. That and I could tell you were nervous about giving his regular dose.

10 units is clearly no where near the right amount of insulin, even if he did get 10 units for a couple days before now and his depot was filled. Please test for ketones each and every day while he is on this much smaller dose. As long as he stays above 300, TR lets you increase every 4 cycles/2 days. Plus if decide to increase in larger amounts, that's OK too.

 

[Jodey&Eddie&Blue]

You hold the syringe, you can increase what you feel comfortable doing. I do recall you said he was "hypo", but was it because they either didn't shoot the right amount or shot earlier than they should have? Or was he not eating enough? Or did he genuinely earn a reduction down from 27 units down the next dose, which at his size dose would be 24-25 units. That was part of the thinking behind my suggestion to reduce his dose. That and I could tell you were nervous about giving his regular dose.

10 units is clearly no where near the right amount of insulin, even if he did get 10 units for a couple days before now and his depot was filled. Please test for ketones each and every day while he is on this much smaller dose. As long as he stays above 300, TR lets you increase every 4 cycles/2 days. Plus if decide to increase in larger amounts, that's OK too.

Yes, I said he went "hypo" on what must have been his first night. I said it because that's what they told me. Was it because they didn't shoot the right amount or shot earlier? I have no idea, which is the problem. Was he not eating enough? They told me he was eating just fine and I have supplied them with his food from home. Did he earn a reduction? The million dollar question. Honestly, that's why this is so crazy-making: at the clinic, the left hand did not know what the right hand was doing, or so it seems.

I'll give this a shot, so to speak. I feel I have to do it this way because I literally do not know what they were doing. I even texted the rad oncologist as she said I could ask questions as she put together his "homecare" instructions and she said, if you can believe this, "I’m definitely not the person to guide you in insulin... ". What? Then who is? You see what I mean.

This has been such a gong show but at least Eddie is eating, drinking, kittyboxing, even purring...

 

[Wendy&Neko]

The radiation oncologist is likely not the person who dealt with his insulin needs. When I went to CSU, we had a team of two vets, an internal medicine vet and a radiation oncologist. The radiation oncologist is ticketed (earned degrees) in two different specialties, imaging and oncology, not internal medicine. There was likely another vet in charge of his insulin care. Now to find out who that was.

 

[Jodey&Eddie&Blue]

The radiation oncologist is likely not the person who dealt with his insulin needs. When I went to CSU, we had a team of two vets, an internal medicine vet and a radiation oncologist. The radiation oncologist is ticketed (earned degrees) in two different specialties, imaging and oncology, not internal medicine. There was likely another vet in charge of his insulin care. Now to find out who that was.

You would think this is the case but she is the one who told me were "trained" to do all this and that I needed to "let them do [their] jobs". Believe me, I have tried and tried and tried and got zero answers or the run around or contradictory answers.

I just have to deal with this tonight and tomorrow morning.